Provider Demographics
NPI:1942531967
Name:ANDERSON, AMY NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 EASTERN SKY DR STE 6
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7351
Mailing Address - Country:US
Mailing Address - Phone:231-932-9014
Mailing Address - Fax:231-932-9034
Practice Address - Street 1:4000 EASTERN SKY DR STE 6
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7351
Practice Address - Country:US
Practice Address - Phone:231-932-9014
Practice Address - Fax:231-932-9034
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010172225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B81315OtherBLUE CROSS BLUE SHIELD MI
MI4797005Medicaid